﻿<?xml version="1.0" encoding="utf-8" ?>
<TransactionSpecification xmlns="http://tempuri.org/X12ParserSpecification.xsd" TransactionSetIdentifierCode="276">
  <Segment SegmentId="BHT"/>
  <Segment SegmentId="REF"/>
  <Loop LoopId="1000">
    <Name>Individual or Organizational Name</Name>
    <StartingSegment SegmentId="NM1"/>
    <Segment SegmentId="N2"/>
    <Segment SegmentId="N3"/>
    <Segment SegmentId="N4"/>
    <Segment SegmentId="REF"/>
    <Segment SegmentId="PER"/>
  </Loop>
  <HierarchicalLoop LoopId="2000A" LevelCode="20">
    <Name>INFORMATION SOURCE LEVEL</Name>
    <Loop LoopId="2100A">
      <Name>Payer Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="PI"/>
        <EntityIdentifier Code="PR"/>
        <EntityIdentifier Code="XV"/>
      </StartingSegment>
    </Loop>
    <Loop LoopId="2200A"> <!-- This might only exist in 005010X214. -->
      <Name>CLAIM SUBMITTER TRACE NUMBER</Name>
      <StartingSegment SegmentId="TRN"/>
      <Segment SegmentId="DTP"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000B" LevelCode="21">
    <Name>INFORMATION RECEIVER LEVEL</Name>
    <Loop LoopId="2100B">
      <Name>Information Receiver Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="41"/>
      </StartingSegment>
    </Loop>
    <Loop LoopId="2200B">
      <Name>Information Receiver Trace</Name>
      <StartingSegment SegmentId="TRN"/>
      <Segment SegmentId="STC"/>
      <!-- This might only exist in 005010X214. -->
      <Segment SegmentId="REF"/>
      <Segment SegmentId="QTY"/> 
      <Segment SegmentId="AMT"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000C" LevelCode="19">
    <Name>SERVICE PROVIDER LEVEL</Name>
    <Loop LoopId="2100C">
      <Name>Provider Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="1P"/>
      </StartingSegment>
    </Loop>
    <Loop LoopId="2200C">
      <Name>Provider of Service Trace Identifier</Name>
      <StartingSegment SegmentId="TRN"/>
      <Segment SegmentId="STC"/>
      <!-- This might only exist in 005010X214. -->
      <Segment SegmentId="REF"/>
      <Segment SegmentId="QTY"/>
      <Segment SegmentId="AMT"/>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000D" LevelCode="22">
    <Name>SUBSCRIBER LEVEL</Name>
    <Segment SegmentId="DMG"/>
    <Loop LoopId="2100D">
      <Name>Subscriber Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="IL"/>
      </StartingSegment>
    </Loop>
    <Loop LoopId="2200D">
      <Name>Claim Status Tracking Number</Name>
      <StartingSegment SegmentId="TRN"/>
      <Segment SegmentId="STC"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="DTP"/>
      <!-- This might only exist in 005010X214. -->
      <Segment SegmentId="QTY"/>
      <Loop LoopId="2210D">
        <Name>Service Level Information</Name>
        <StartingSegment SegmentId="SVC"/>
        <Segment SegmentId="STC"/>
        <Segment SegmentId="REF"/>
        <Segment SegmentId="DTP"/>
      </Loop>
    </Loop>
  </HierarchicalLoop>
  <HierarchicalLoop LoopId="2000E" LevelCode="23">
    <Name>DEPENDENT LEVEL</Name>
    <Segment SegmentId="DMG"/>
    <Loop LoopId="2100E">
      <Name>Dependent Name</Name>
      <StartingSegment SegmentId="NM1">
        <EntityIdentifier Code="QC"/>
      </StartingSegment>
    </Loop>
    <Loop LoopId="2200E">
      <Name>Claim Status Tracking Number</Name>
      <StartingSegment SegmentId="TRN"/>
      <Segment SegmentId="STC"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="AMT"/>
      <Segment SegmentId="DTP"/>
      <!-- This might only exist in 005010X214. -->
      <Segment SegmentId="QTY"/>
      <Loop LoopId="2210E">
        <Name>Service Line Information</Name>
        <StartingSegment SegmentId="SVC"/>
        <Segment SegmentId="STC"/>
        <Segment SegmentId="REF"/>
        <Segment SegmentId="DTP"/>
      </Loop>
    </Loop>
  </HierarchicalLoop>
  <!-- This loop only appears in 5010X214 Claim Acknowledgment -->
  <HierarchicalLoop LoopId="2000D" LevelCode="PT">
    <Name>PATIENT LEVEL</Name>
    <Loop LoopId="2100D">
      <Name>Patient Name</Name>
      <StartingSegment SegmentId="NM1">
      </StartingSegment>
    </Loop>
    <Loop LoopId="2200D">
      <Name>Claim Status Tracking Number</Name>
      <StartingSegment SegmentId="TRN"/>
      <Segment SegmentId="STC"/>
      <Segment SegmentId="REF"/>
      <Segment SegmentId="DTP"/>
      <Segment SegmentId="QTY"/>
      <Loop LoopId="2220D">
        <Name>Service Line Information</Name>
        <StartingSegment SegmentId="SVC"/>
        <Segment SegmentId="STC"/>
        <Segment SegmentId="REF"/>
        <Segment SegmentId="DTP"/>
      </Loop>
    </Loop>
  </HierarchicalLoop>
</TransactionSpecification>